Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: General Medicine

A branch of medicine that deals with diagnosis and treatment of nonsurgical diseases.



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Request For Consultation
Request for consultation to evaluate stomatitis, possibly methotrexate related.

Revocation Admission
A 40-year-old male seen today for a 90-day revocation admission. Noncompliant with medications, refusing oral or IM medications, became agitated. History of hyperlipidemia with elevated triglycerides.

Right Hand Laceration
Right hand laceration x3, repaired.

Sepsis - Consult
Sepsis. The patient was found to have a CT scan with dilated bladder with thick wall suggesting an outlet obstruction as well as bilateral hydronephrosis and hydroureter.

Shortness Of Breath - Progress Note
The patient was admitted approximately 3 days ago with increasing shortness of breath secondary to pneumonia. Pulmonary Medicine Associates have been contacted to consult in light of the ICU admission.

Sleep Apnea
Followup of moderate-to-severe sleep apnea. The patient returns today to review his response to CPAP. Recommended a fiberoptic ENT exam to exclude adenoidal tissue that may be contributing to obstruction.

Sleep Study Followup
Followup after a full-night sleep study performed to evaluate her for daytime fatigue and insomnia. This patient presents with history of sleep disruption and daytime sleepiness with fatigue. Her symptoms are multifactorial.

Sleepiness - Consult
Severe back pain and sleepiness. The patient, because of near syncopal episode and polypharmacy, almost passed out for about 3 to 4 minutes with a low blood pressure.

Snoring
Chronic snoring in children

SOAP - Substance Abuse
He got addicted to drugs. He decided it would be a good idea to get away from the "bad crowd" and come up and live with his mom.

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NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports. These transcribed medical transcription sample reports may include some uncommon or unusual formats; this would be due to the preference of the dictating physician. All names and dates have been changed (or removed) to keep confidentiality. Any resemblance of any type of name or date or place or anything else to real world is purely incidental.
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Transcribed Medical Transcription Sample Reports and Examples